Hypoglycemia + Heart = Things You Need To Know ASAP

Does this illustration scare you?

It should.

I first encountered this slide during an academic lecture given by Dr. Mikhail Kosiborod, MD when I attended the International Hospital Diabetes Meeting in May. He was sharing data about cardiovascular events and outcomes. (If you’re not an academic, the smart people begin to sound like Charlie Brown’s teachers after a while.) But when this illustration came onto the screen, I frantically scribbled the study’s authors down.

This slide was the first time I saw so plainly what was happening to me when I had a moderate hypoglycemic episode. (Dr. Kosiborod said that a “moderate” hypo was 57 mg/dl or less.) Not just the “I feel like I’m dizzy and not all here and let’s concentrate on something insignificant and is it hot in here?” reaction. This was what was going on inside without me feeling most of it.

Complications are not always from high blood glucose levels

We all know the long-term implications of high blood sugars. It’s that same old “-Opathy” chant that everyone sings loudly: “Retinopathy-neuropathy-nephropathy” with the back-up singers humming: “Don’t forget about stroke and amputation and arteriosclerosis and…big finish, everyone! Gum disease!”

But with lows, it’s a quick ditty: “Unconciousness, seizure, death.” It’s not a chart-topper, but it can be #1 with a bullet if you’re hypoglycemic. When I had those times of “Whoa…let’s stand in the kitchen and daze off into space,” it didn’t feel like I was doing any damage to my body. Sure, I felt like my head had been run over by Gravedigger and I was treading in molasses for several hours after some lows, but I recovered. Or so I thought. Now?

I am setting myself up for long-term complications with repeated moderate low blood sugars. So are you.

Here’s what happens (you can follow along with the slide, but I’ll break it down in terms we all understand):

Inflammation

Every moderate hypoglycemic reaction sends out wonderful proteins to increase inflammation in our body. (I’ll cut to the chase. We don’t want that.) They are:

Vascular endothelial growth factor (VEGF ), is a signal protein that helps to promote the growth of new blood vessels. We need VEGF as we grow in a womb (to create the blood vessels), after exercise or injury, and VEGF can help create new blood vessels when there is an obstruction. But, much like really good food, it’s only good in moderation. Too much of it (“overexpression”) can contribute to asthma, retinal problems, and cancers. The levels go up when we have a moderate hypoglycemic episode.

Interleukin 6 (IL-6) is an interleukin (No, I’m not a medical professional or a biology whiz, so I had to look it up. Fancy word for protein) that does double duty: it promotes inflammation and can help with healing in certain situations. In this case, when we have a low, it’s under the inflammation category. And it gets busy.

Endothelial Dysfunction

Vasoconstriction, the narrowing of blood vessels, is not something you want unless you need to stop a massive bleed. But, when you don’t need to stop a hemorrhage, it’s not often something super to have going on. Vasoconstriction raises blood pressure (which is why vasoconstrictor medications are given to people with low blood pressure) and can cause erectile dysfunction. You know what else causes vasoconstriction? Caffeine. Sigh.

Time for a breather. Here’s a picture of a bunny, because this stuff is pretty heavy. Warning, after the bunny, there are no more cute things.

Neutrophils are white blood cells. When inflammation starts, neutrophils head towards the area of inflammation. Because our body is doing the inflammation dance when we’re having a moderate low, neutrophils show up for the party, too.

Platelet Activation – platelets help to staunch bleeding by clumping and clogging a blood vessel. Great for stopping bleeding, of course, but lousy when the result is thrombosis. We increase platelet activation when we’re low.

Sympathoadrenal Response

We release adrenaline, epinephrine and norepinephrine as our blood sugar sinks into the basement. It’s that “fight or flight” feeling; that “out-of-control and my heart is racing” feeling. It’s our body’s adrenal response to get us to do something.

When we have multiple hypos, we can developed a suppressed sympathoadrenal response – and that’s hypoglycemic unawareness. Clinicians talk about raising a target blood glucose level because a person with diabetes has hypo unawareness to retrain the body to have that adrenal response again.

But your nervous system also factors into play here. Your autonomic nervous system. Your heart is part of this system. A moderate hypo causes your heart to beat faster (“Thud-thud-thud”) and can cause long-term issues with the timing of your heart (arrhythmia). We’re making our hearts work harder.

It’s Not Over When You Think It’s Over

Your blood glucose level comes up and the hypo is over. But what happened to your body is not over. Not by a longshot. This is what I learned at the symposia at ADA’s 75th Scientific Sessions on Hypoglycemia.

And it’s this:

Vascular issues can last up to two days and blood coagulation issues for up to a week.
Every moderate hypoglycemic episode builds up inflammation and coagulation responses in my body. One sucky hypo a week was not uncommon for me, even with a Dexcom.

What Am I Doing Now?

I’m doing everything to prevent a moderate or severe low blood sugar. The research I did shows me that I can change the way I react to my lows and help prevent these “issues” from happening.

My CGM is constantly on my body and I’ve set it to alarm at 80mg/dl so that I’m still in my right mind to look at it and take action if I need to do so. Has this helped?

Yes.

Instead of alarming at 70, when I often tell myself that I’m invincible and that my blood sugar will go back up on its own (I’ve said this to myself a lot…Yes, I know. False.), I’m catching that low. It also has prevented the response of eating everything in the kitchen because I’m in “fight or flight” (or “stuff your face or pass out”) mode. My stress level is lower and I feel more in control.

And that is what this post is about… giving you the info and giving you the opportunity to help yourself, because while you can’t control having diabetes, you can control how you manage it. And hypos are not so innocent.

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0 comments

I have been a type 1 for better than 38 years and this is the first time I have heard about the hazards of the lows we all get. Years ago I would never have even worried about this but now that I am being driven to the new “tight” control I have these pesky lows more often. Nice article. And thanks for the info.

I cannot fully agree with the article you have found. Let me explain. here are so many Joslin Medalists, with 50+ years of T1, who do not have serious D problems. We have discussed our past experiences in the FB Joslin Medalists group , and most of us have had many lows and highs. Passing out, going to the ER kind of lows, and highs. We are still doing very well. Some have had stents, and bypasses, but they still thrive. Many of us had seizures when we were young. I had many of those, but no more. My nuclear stress tests, every 3 years, show that my heart is healthy. It is hard to understand how inflammation with hypos can damage some people, but not others. I am thinking that there is some exaggeration in the article.

I do agree with your using tight control, I certainly do that. Your CGM is a great idea. Maybe I will get to use one someday.

Hi Christel,
Thanks for a great article. It was a good move to up your level on the CGM from 70 mg/dL to 80 mg/dL.
To deal with the sleeping period, I have set the level on my CGM lower level to 90 mg/dL. I find that it gallows me a
larger window of opportunity to deal with falling number relative to the speed of the drop. As always have a great
day.
Dan

I wish there was more information about long term effects of moderate hypos and why don’t doctors talk about this more? As you say, we all know the risks of prolonged hyperglycemia as well as severe hypoglycemia, but with the tools we have available today to intensify treatment, the probably of frequent moderate hypos is higher and these risks are not on our radar. Thank you for posting this!

This is probably the most valuable bit of advice I’ve read in years online. Something about lowering an a1c, and accepting more low blood sugars, never felt right! Every person with diabetes needs to read this. Thanks for writing such a comprehensive guide.

Christel, I’m so glad you made this post! I had seen the slide and read the info a while back when it first appeared in the DOC, but then my brain forgot where I had seen it when I went to share with the hubs and kiddo. Now they get to see the cute bunny.
Thank you for the cute bunny.

I am not Diabetic, but my daughter is… My question is, what is really considered a “hypoglycemic episode “?
I wore my daughters CGM for a week, and my blood sugar tended to hang out around 70 to 80 range 80% of the time. The only time I felt “low”, I was below 60.
I try to keep my daughters blood glucose level above 80, but I’ve been wondering if a slightly lower threshold would be acceptable?

Amanda, That’s a great question. Please remember that I am not a medical professional, so this is something that you would want to discuss with your daughter’s healthcare team. Changing my CGM level to alarm at 80 mg/dl allows me to catch lows before they truly begin. Once the alarm goes off, I see which way the arrow is moving (and at what rate) and take appropriate action (i.e. a BG check and then a few carbs or more, depending on what the results is…)